Regulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)

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1 Federal Employee Program 1310 G Street, N.W. Washington, D.C Fax Subject: Orencia Page: 1 of 6 Last Review Date: December 8, 2017 Orencia Description Orencia (abatacept) Background Orencia is a prescription medication that reduces signs and symptoms in adults with moderate to severe rheumatoid arthritis (RA), including those who have experienced an inadequate response to other medications for RA. Orencia may prevent further damage to bones and joints and may help the patient s ability to perform daily activities. In adults, Orencia may be used alone or with other RA treatments other than tumor necrosis factor (TNF) antagonists (1). Orencia is indicated to reduce the signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis (JIA) in pediatric patients 2 years of age and older. Patients may receive Orencia alone (monotherapy) or in combination with methotrexate (1). Regulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1) 1. Adult Rheumatoid Arthritis (RA) Moderately to severely active RA in adults. Orencia may be used as monotherapy or concomitantly with DMARDs other than TNF antagonists 2. Juvenile Idiopathic Arthritis Moderately to severely active polyarticular juvenile idiopathic arthritis in pediatric patients 2 years of age and older. Orencia may be used as monotherapy or concomitantly with methotrexate

2 Subject: Orencia Page: 2 of 6 3. Adult Psoriatic Arthritis (PsA) active PsA in adults Limitations of Use: Orencia should not be given concomitantly with TNF antagonists as it can increase the risk of infections and serious infections (1). Physicians should exercise caution when considering the use of Orencia in patients with a history of recurrent infections, underlying conditions which may predispose them to infections, or chronic, latent, or localized infections. Patients who develop a new infection while undergoing treatment with Orencia should be monitored closely. Administration of Orencia should be discontinued if a patient develops a serious infection. A higher rate of serious infections has been observed in adult RA patients treated with concurrent TNF antagonists and Orencia (1). Prior to initiating immunomodulatory therapies, including Orencia, patients should be screened for latent tuberculosis infection with a tuberculin skin test. Orencia has not been studied in patients with a positive tuberculosis screen, and the safety of Orencia in individuals with latent tuberculosis infection is unknown. Patients testing positive in tuberculosis screening should be treated by standard medical practice prior to therapy with Orencia (1). Antirheumatic therapies have been associated with hepatitis B reactivation. Therefore, screening for viral hepatitis should be performed in accordance with published guidelines before starting therapy with Orencia. In clinical studies with Orencia, patients who screened positive for hepatitis were excluded from study (1). The safety and effectiveness of Orencia in pediatric patients below 2 years of age have not been established (1). Related policies Actemra, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Remicade, Simponi, Stelara, Xeljanz Policy This policy statement applies to clinical review performed for pre-service (Prior Approval, Precertification, Advanced Benefit Determination, etc.) and/or post-service claims. Orencia may be considered medically necessary for patients age 2 or older for the treatment of juvenile rheumatoid arthritis (JRA)/ active polyarticular juvenile idiopathic arthritis (pjia) and if the conditions below are met.

3 Subject: Orencia Page: 3 of 6 Orencia may be considered medically necessary for patients age 18 or older for the treatment of rheumatoid arthritis (RA), or active psoriatic arthritis (PsA) and if the conditions below are met. Orencia may be considered investigational for all other ages and indications. Prior-Approval Requirements Diagnoses Patient must have ONE 1. Moderately to severely active rheumatoid arthritis (RA) b. Inadequate treatment response, intolerance, or contraindication to at least a 3-month trial of methotrexate c. Prescriber will be dosing the patient within the FDA labeled dose of ONE i. IV infusion: Less than 60 kg 500 mg every 4 s ii. IV infusion: 60 kg to 100kg 750 mg every 4 s iii. IV infusion: More than 100 kg 1000 mg every 4 s iv. Subcutaneous administration: 125 mg every 2. Active Juvenile Rheumatoid Arthritis (JRA)/ Polyarticular Juvenile Idiopathic Arthritis (pjia) a. 2 years of age or older b. Inadequate treatment response, intolerance, or contraindication to at least a 3-month trial of a TNF inhibitor c. Prescriber will be dosing the patient within the FDA labeled dose of ONE i. IV infusion: Less than 75kg 10mg/kg every 4 s ii. Subcutaneous administration: 10 to less than 25 kg 50 mg every iii. Subcutaneous administration: 25 to less than 50 kg 87.5 mg every iv. Subcutaneous administration: More than 50 kg 125 mg every

4 Subject: Orencia Page: 4 of 6 3. Active Psoriatic Arthritis (PsA) b. Inadequate treatment response, intolerance, or contraindication to at least a 3-month trial of a TNF inhibitor c. Prescriber will be dosing the patient within the FDA labeled dose of ONE i. IV infusion: Less than 60 kg 500 mg every 4 s ii. IV infusion: 60 kg to 100kg 750 mg every 4 s iii. IV infusion: More than 100 kg 1000 mg every 4 s iv. Subcutaneous administration: 125 mg every AND ALL 1. Tuberculin skin test conducted to rule out TB a. Patients testing positive in tuberculosis screening must be treated by standard medical practice currently or completed prior to therapy. 2. Hepatitis B virus (HBV) has been ruled out or treatment initiated. 3. NO active infection 4. NOT to be used in combination with any other biologic DMARD or targeted synthetic DMARD 5. NOT given concurrently with live vaccines Prior Approval Renewal Requirements Diagnoses Patient must have ONE 1. Rheumatoid Arthritis (RA) in adults b. Prescriber will be dosing the patient within the FDA labeled dose of ONE i. IV infusion: Less than 60 kg 500 mg every 4 s ii. IV infusion: 60 kg to 100kg 750 mg every 4 s iii. IV infusion: More than 100 kg 1000 mg every 4 s iv. Subcutaneous administration: 125 mg every 2. Juvenile Rheumatoid Arthritis (JRA)/Polyarticular Juvenile Idiopathic Arthritis

5 Subject: Orencia Page: 5 of 6 (pjia) a. 2 years of age or older b. Prescriber will be dosing the patient within the FDA labeled dose of ONE i. IV infusion: Less than 75kg 10mg/kg every 4 s ii. Subcutaneous administration: 10 to less than 25 kg 50 mg every iii. Subcutaneous administration: 25 to less than 50 kg 87.5 mg every iv. Subcutaneous administration: More than 50 kg 125 mg every 3. Psoriatic Arthritis (PsA) b. Prescriber will be dosing the patient within the FDA labeled dose of ONE i. IV infusion: Less than 60 kg 500 mg every 4 s ii. IV infusion: 60 kg to 100kg 750 mg every 4 s iii. IV infusion: More than 100 kg 1000 mg every 4 s iv. Subcutaneous administration: 125 mg every AND ALL 1. Condition has improved or stabilized 2. Absence of active infection (including tuberculosis and hepatitis B virus (HBV)) 3. NOT to be used in combination with any other biologic DMARD or targeted synthetic DMARD 4. NOT given concurrently with live vaccines Policy Guidelines Pre - PA Allowance None Prior - Approval Limits Duration 12 months

6 Subject: Orencia Page: 6 of 6 Prior Approval Renewal Limits Duration 18 months Rationale Summary Orencia is indicated for the treatment of moderately to severely active RA and PsA in adults, may be used as monotherapy or concomitantly with DMARDs other than TNF antagonists. Orencia is also indicated for pediatric patients 2 years of age or older with moderately to severely active polyarticular juvenile idiopathic arthritis, may be used as monotherapy or concomitantly with methotrexate. Prior to initiating immunomodulatory therapies, including Orencia, patients should be screened for latent tuberculosis infection with a tuberculin skin test. Antirheumatic therapies have been associated with hepatitis B reactivation (1). Prior authorization is required to ensure the safe, clinically appropriate and cost effective use of Orencia while maintaining optimal therapeutic outcomes. References 1. Orencia [package insert]. Princeton, NJ: Bristol-Myers Squibb; June Policy History Date April 2008 September 2012 March 2013 September 2013 September 2014 March 2016 September 2016 Action FDA approved Abatacept (Orencia) for reducing signs and symptoms in pediatric patients six years and older with moderately to severely active polyarticular juvenile idiopathic arthritis (JIA). Annual editorial review and reference update Annual editorial review and reference update; updated contraindicated concomitant therapies and any live vaccine. Annual editorial review and reference update. Addition of TB testing, no hepatitis B virus, and no active infection requirements to the criteria. Annual editorial review and reference update and renewal limit to 18 months Annual editorial review and reference update Policy number changed from to Annual editorial review Addition of not given concurrently with live vaccines per SME

7 Subject: Orencia Page: 7 of 6 December 2016 April 2017 June 2017 July 2017 September 2017 December 2017 Annual editorial review and reference update Additional criteria added to initiation for treatment of RA: Contraindication, intolerance, or inadequate treatment response to at least a 3-month trial of methotrexate despite adequate dosing Additional criteria added to initiation for treatment of JRA/pJIA: Contraindication, intolerance, or inadequate treatment response to at least a 3-month trial of a TNF inhibitor Addition of FDA approval for ages two years and older for JRA/pJIA Annual review Addition of Psoriatic Arthritis (PsA) and dosing requirements for each indication Annual review Annual review Keywords This policy was approved by the FEP Pharmacy and Medical Policy Committee on December 8, 2017 and is effective on January 1, 2018.